Here we go again: The politically correct but scientifically mistaken attack on twin pregnancies in association with IVF

Posted on December 5th, 2014

It started in Europe but now has crossed the Atlantic. It has become the “politically correct” thing to say in the U.S. : “Twin pregnancies after infertility treatments, especially in association with IVF, represent an undesired treatment outcome and, therefore, should be avoided.”

The Economist, usually a well-informed publication when reporting on medical developments, fell into this trap in an article in its November 22 edition under the subtitle “A reduction in multiple-birth pregnancies is a good thing.” The article reports on the declining multiple pregnancy rates in the U.K. as a consequence of a policy adopted by the Human Fertilisation and Embryology Authority (HEFA), the governing regulator of IVF in the U.K, a few years ago.

CHR has repeatedly commented on this subject on our website, and CHR investigators have published a number of manuscripts in peer reviewed journals (please contact us for reprints). CHR very clearly disagrees with the prevailing “political correctness” on the subject of multiple births after IVF. Interested readers are referred to these materials for detailed insights.

In response to The Economist article, we here, however, want to recapitulate a few points of importance:

CHR agrees that high order multiple births (triplets or higher order multiples) represent adverse outcomes of fertility treatments and, therefore, should be avoided. CHR, however, does not agree to the assertion that, even in the absence of medical contraindications in the mother, twin pregnancies represent undesired outcomes and should be avoided.

Our disagreement with colleagues in regard to twin pregnancies is based on the indisputable fact that risk statistics that assign twin pregnancies higher maternal and neonatal risks than singleton pregnancies are based on incorrect statistical methodology: It is statistically incorrect to compare outcomes of twin pregnancies to outcomes of singleton pregnancies in a fertility treatment paradigm, because such a comparison compares incomparable outcomes. Twin pregnancies result in delivery of two neonates and singleton pregnancies in delivery of only one child. Statistically correct risk comparisons can only be made by comparing identical outcomes; in this case the delivery of two neonates. A correct statistical comparison, therefore, is not between one twin and one singleton pregnancy but between one twin and two singleton pregnancies! When this is done, twin pregnancies no longer demonstrate significant maternal and/or neonatal mortality and morbidity.

If there is no increased mortality and/or morbidity associated with twin deliveries, there is also no associated increase in cost.

Indeed, unintended detrimental effects are brought to patients because elective single embryo transfer (eSET), which is widely propagated as the “tool of choice” in reducing twin pregnancy risk, has been repeatedly shown to reduce pregnancy chances, therefore requiring more IVF cycle activity to achieve similar pregnancy chances and, thus, increasing costs.

Finally, multiple studies have demonstrated unequivocally that even well-educated infertility patients in a large majority are willing to take additional calculated risks of twin pregnancies to achieve higher pregnancy chances and actually favor twin pregnancies when there are no medical contraindications. Mandated eSET policies, as for example practiced in the U.K. based on HEFA rules, therefore, are contradictory to the right of self determination Western societies claim to offer their citizens.

While political correctness on this subject has, unfortunately, also been expanding in the U.S., daily IVF practice is, fortunately, so far much less affected than in European countries. One positive consequence is the still significantly higher IVF pregnancy rates on this side of the Atlantic. It is really quite remarkable how “unimportant” in Europe pregnancy success has become to many colleagues.

In many ways, the issue of twin pregnancies, therefore, reflects very basic differences in the philosophy of health care between the U.S. and Europe. On the other side of the Atlantic, it is the provider infrastructure, made up of physicians and government payers, that determines practice patterns. Here in the U.S., at least when it comes to IVF, it still is to a large degree the patient who decides on her treatment, since most patients do not have insurance and/or government coverage for IVF.

As long as the patient can decide what is best for them, the likelihood of rational decisions is high. Once insurance companies and/or government interests enter the picture, the patients’ individual interests are strongly diluted in favor of what is politically perceived as the “larger good” of society. But as often is the case, government is not well suited to determine what the “larger good” of society really is, and for insurance companies it is usually primarily defined by immediate rather than long-term expenses.

The Economist, usually quite astute when it comes to understanding health care policy, may want to consider these insights!

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